Physicians Mutual Insurance Company®
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The chart below shows the covered dental procedures Physicians Mutual Insurance Company pays benefits for, as well as the maximum expense paid for each.
Customers with this coverage have access to discounts through the Ameritas Classic PPO Network.
- The amounts shown are the same regardless of provider participation. There are no penalties for seeing a Non-Participating Provider.
- Only the procedures listed receive benefits for the schedule (A, D or E) for the plan option selected.
- For Participating Providers, the amount paid will not exceed the Maximum Allowable Charge.
- For Non-Participating Providers, the amount paid will not exceed the amount of the actual charge for the procedure.
Covered procedures may vary by state and are subject to change. No benefits are payable for a procedure that is not listed.
If you have any questions, give us a call at 1-800-469-81381-800-469-8138.
| Type I - Preventive |
|---|
Code D0120 Description Periodic oral evaluation – established patient. ECO + STA + PRE + $34 $39 $44 |
Code D0145 Description Oral evaluation for a patient under three years of age and counseling with primary caregiver. ECO + STA + PRE + $31 $34 $38 |
Code D0150 Description Comprehensive oral evaluation – new or established patient. ECO + STA + PRE + $41 $49 $57 |
Code D0180 Description Comprehensive periodontal evaluation – new or established patient. ECO + STA + PRE + $41 $49 $57 |
| Two evaluations will be allowed in a Policy Year. A D0120, D0145, D0150 or D0180 counts toward this maximum allowance. D0150 and D0180 will be limited to once per provider. |
Code D0210 Description Intraoral – complete series of radiographic images. ECO + STA + PRE + $44 $60 $77 |
Code D0330 Description Panoramic radiographic image. ECO + STA + PRE + $45 $59 $72 |
| D0210 or D0330: One of these procedures will be allowed in a 5-year period.* |
| Type II - Basic |
|---|
Code D0140 Description Limited oral evaluation - problem focused. ECO + STA + PRE + $19 $25 $32 |
Code D0170 Description Re-evaluation - limited, problem focused (established patient; not post-operative visit). ECO + STA + PRE + $19 $25 $32 |
| D0140 and D0170: Coverage is limited to accidental injury only. If not due to an accident, will be considered as a D0120 and count toward this maximum allowance. |
Code D0472 Description Accession of tissue, gross examination, preparation and transmission of written report. ECO + STA + PRE + $22 $30 $38 |
| Type III - Major |
|---|
Code D3220 Description Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament. ECO + STA + PRE + $29 $40 $49 |
Code D3221 Description Pulpal debridement, primary and permanent teeth. ECO + STA + PRE + $29 $40 $49 |
Code D3222 Description Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development. ECO + STA + PRE + $44 $60 $73 |
Code D3230 Description Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration). ECO + STA + PRE + $39 $53 $65 |
Code D3240 Description Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration). ECO + STA + PRE + $34 $46 $56 |
Type I - Preventive | Maximum Covered Expense | |||
|---|---|---|---|---|
| Code | Economy Plus Schedule A | Standard Plus Schedule D | Preferred Plus Schedule E | |
| D0120 | Periodic oral evaluation – established patient. | $34 | $39 | $44 |
| D0145 | Oral evaluation for a patient under three years of age and counseling with primary caregiver. | $31 | $34 | $38 |
| D0150 | Comprehensive oral evaluation – new or established patient. | $41 | $49 | $57 |
| D0180 | Comprehensive periodontal evaluation – new or established patient. | $41 | $49 | $57 |
| Two evaluations will be allowed in a Policy Year. A D0120, D0145, D0150 or D0180 counts toward this maximum allowance. D0150 and D0180 will be limited to once per provider. | ||||
| D0210 | Intraoral – complete series of radiographic images. | $44 | $60 | $77 |
| D0330 | Panoramic radiographic image. | $45 | $59 | $72 |
| D0210 or D0330: One of these procedures will be allowed in a 5-year period.* | ||||
Type II - Basic | Maximum Covered Expense | |||
|---|---|---|---|---|
| Code | Economy Plus Schedule A | Standard Plus Schedule D | Preferred Plus Schedule E | |
| D0140 | Limited oral evaluation - problem focused. | $19 | $25 | $32 |
| D0170 | Re-evaluation - limited, problem focused (established patient; not post-operative visit). | $19 | $25 | $32 |
| D0140 and D0170: Coverage is limited to accidental injury only. If not due to an accident, will be considered as a D0120 and count toward this maximum allowance. | ||||
| D0472 | Accession of tissue, gross examination, preparation and transmission of written report. | $22 | $30 | $38 |
Type III - Major | Maximum Covered Expense | |||
|---|---|---|---|---|
| Code | Economy Plus Schedule A | Standard Plus Schedule D | Preferred Plus Schedule E | |
| D3220 | Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament. Limited to treatment of primary teeth. | $29 | $40 | $49 |
| D3221 | Pulpal debridement, primary and permanent teeth. | $29 | $40 | $49 |
| D3222 | Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development. | $44 | $60 | $73 |
| D3230 | Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration). | $39 | $53 | $65 |
| D3240 | Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration). | $34 | $46 | $56 |